|Any healthcare provider can offer their patients the services of the Tobacco Quitline as the next step in helping them quit. The Consent/Referral form is HIPAA approved and allows the Tobacco Quitline to make a proactive contact with the patient instead of waiting for the patient to call us. The form also specifies that the patient will allow follow up and progress information to be given to the healthcare provider that will become part of their chart and can be reviewed on each visit.
Working together, we can help patients take advantage of professional, trained staff who will help with a quit plan, quit date and support to be as successful as they can be. Healthcare providers can rely on the Tobacco Quitline to engage the patient and provide the behavior change support that has been proven to succeed.
A Medical Clearance Form is sent to the callers healthcare provider when a caller reports any conditions that may inhibit or question the use of nicotine replacement products or medications. In these cases, no products will be distributed without a medical clearance form signed and returned.
Healthcare providers may request quarterly reports on referrals to the Tobacco Quitline. A list of patients referred by Consent/Referral form will be provided with the contact, progress and follow up information.
Pregnant callers who request the use of nicotine replacement products would be required to provide the name and contact information of their primary care physician. A special form is faxed to the provider to include the approval/denial of use of nicotine replacement. In the case of approval, the Tobacco Quitline requires the form to be completed as a prescription for the specific product and dosage approved for use by the pregnant caller. No nicotine replacement products will be distributed to any pregnant caller without receipt of this approval.
Click here for the Online Referral Form or to become a registered healthcare provider.
Click here to download a Medical Clearance Form (If Pregnant) (PDF Format)
Click here to download a Medical Clearance Form (If Pregnant) (Word Document Format)
Click here for the Fax Referral Form (PDF Format)
Call 1-800-QUITNOW or 1-800-784-8669 Or For Free Online Support Click Here
Hours of Operation
Monday through Thursday - 7 a.m. - 9 p.m.
Friday - 7 a.m. - 7 p.m.
Saturday - 9 a.m. - 5:30 p.m.
Sunday - Voicemail is available
Days of Operation
The Mississippi Tobacco Quitline is open Monday through Saturday except for recognized holidays: Christmas Eve, Christmas Day, Martin Luther King Jr. Day, Memorial Day, Fourth of July, Labor Day, and Thanksgiving Day.